Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 10
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 10-01-12 and 12-31-12 Date of Report: 02-16-13 Page: 1
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Service Coordination, Class # 01
SCONLY-SCONLY SERVICE COORDINATION ONLY 119 143 88.788879 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 119 143 88.788879 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 30 31 10.233331 $133.5400 $13.0500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 30 31 10.233331 $93.2200 $9.1100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 30 31 10.233331 $95.5800 $9.3400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 30 31 10.233331 $222.3700 $21.7300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 25 26 9.188887 $224.8500 $24.4700
AUDE -AUDE UNSPECIFIED AUDE SERVICES 26 30 71.322224 $4279.3400 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.688889 $31.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.111111 $357.7800 $115.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 23 43.900001 $2129.1500 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 1.944445 $94.3100 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 18 20 17.633334 $855.2200 $48.5000
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Subtotal (Total Children Is Unduplicated) 90 232 188.722215 $8516.3600 $45.1300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 6.000000 $9000.0000 $1500.0000
AUD -HA_FUP AUDIOLOGY SERVICES 8 8 25.742856 $1287.1500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 106 133 25.272228 $1263.6400 $50.0000
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 5 5 1.016668 $25.4200 $25.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 195 242 92.077769 $4603.8500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 149 184 118.933325 $5946.6300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 0.427778 $10.7000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 95 124 106.371424 $5318.5500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 370 486 290.849980 $14542.4000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 6.133333 $153.3300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 21 25 157.904767 $3947.6300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.600000 $480.0000 $50.0000
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 5.200000 $130.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 307 444 4042.760330 $202138.0800 $50.0000
INTR -INTR INTERPRETER 3 5 12.383333 $619.1700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 116 162 830.000007 $56340.4500 $67.8800
OCCT -97530HM OT SESSION BY OT ASST 4 4 20.400000 $1108.1300 $54.3200
PHY -97110 PT SESSION BY LICENSED PT 130 182 785.633332 $53328.7800 $67.8800
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 2.111111 $1055.5500 $500.0000
SENS -V5264 EARMOLD 2 2 2.111111 $38.0000 $18.0000
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 0.800000 $40.0000 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 210 290 1570.561906 $106609.7500 $67.8800
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 5.600000 $73.9200 $13.2000
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1007 1697 340723.788861 $170361.8900 $0.5000
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 1 1 9.200000 $460.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 1191 4004 348850.880119 $638882.9800 $1.8300
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Total 4379 349128.391213 $647399.3400 $1.8500
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Number of Children (Unduplicated) With at Least One Authorization 1303